eMedicine Specialties > Obstetrics and Gynecology > General Gynecology

Missed Abortion: Differential Diagnoses & Workup

Author: James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of Medicine
Coauthor(s): Veronica R Rivera, MD, Staff Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Oct 9, 2008

Differential Diagnoses

Ectopic Pregnancy
Hydatidiform Mole

Other Problems to Be Considered

Normal intrauterine pregnancy
Complete spontaneous abortion
Incomplete abortion
Inevitable abortion
Multiple gestation

Workup

Laboratory Studies

Lab studies for missed abortion include the following:

  • Quantitative hCG levels
    • Quantitative hCG levels are useful for very early pregnancy evaluation when no sac is visible in the uterus on sonogram.
    • If suspicion of ectopic pregnancy exists, levels should be obtained at 48-hour intervals until the discriminatory level is reached. The discriminatory level of hCG is the level at which an intrauterine pregnancy should always be visible on vaginal probe ultrasonography. In most institutions, this is about 1500-2000 mIU/mL when standardized to the International Reference Preparation (IRP).
    • Once the sac is clearly observed in the uterus, lower-than-expected levels of hCG or progesterone increase the possibility for abnormal pregnancy but are not diagnostic. Therefore, imaging studies are the studies of choice.
  • Coagulation studies are generally not indicated prior to evacuation of the uterus.
  • Documenting Rh status and treating appropriately if the woman is Rh negative is important.

Imaging Studies

  • Ultrasonography
    • Once the hCG level has reached the discriminatory level, vaginal ultrasonography replaces blood tests as the primary means of evaluation.
    • If a true intrauterine gestational sac is observed, ectopic pregnancy is ruled out. For naturally conceived pregnancies, the coexistence of ectopic and intrauterine pregnancy is extremely rare (1 out of 30,000 pregnancies). However, with assisted reproduction technology, consider the coexistence of an ectopic and intrauterine pregnancy.
    • After a sac has been demonstrated in the uterus, the next step is to determine if the pregnancy is normal or abnormal. Transvaginal ultrasonography is the best imaging procedure to evaluate intrauterine contents.
    • While some ultrasonography criteria strongly support the diagnosis, most patients and physicians prefer to use repeat ultrasonography to confirm that the pregnancy is a missed abortion and not simply an early normal pregnancy. In most cases, a repeat ultrasonography in 1 week confirms lack of progressive development. In the case of a very early pregnancy where the sac diameter is less than 5-6 mm, repeating the study in 10-14 days may be more effective.
    • Serial ultrasonography is unnecessary if ultrasonography reveals loss of previously documented heart activity.
    • Transvaginal ultrasonography criteria that strongly suggest embryonic demise include a crown-rump length that is greater than 5 mm without cardiac activity. The criterion that suggests a blighted ovum is a mean gestational sac diameter greater than 16 mm with absence of embryo or a mean gestational sac diameter greater than 8 mm and no yolk sac.

Other Tests

More extensive tests, such as chromosomal analysis, are not usually indicated. However, in cases of recurrent losses, karyotyping of the parents can be useful.

Procedures

Histologic Findings

Histologic findings are similar to that of spontaneous abortion. Varying amounts of placental and/or fetal tissue should be present and are usually reported as products of conception.

More on Missed Abortion

Overview: Missed Abortion
Differential Diagnoses & Workup: Missed Abortion
Treatment & Medication: Missed Abortion
Follow-up: Missed Abortion
Multimedia: Missed Abortion
References
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References

  1. [Best Evidence] Nanda K, Peloggia A, Grimes D, Lopez L, Nanda G. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2006;(2):CD003518. [Medline].

  2. American College of Obstetrics and Gynecology. Early Pregnancy Loss. The American College of Obstetrics and Gynecology, Compendium of Selected Publications. 1995.

  3. Bagratee JS, Khullar V, Regan L, et al. A randomized controlled trial comparing medical and expectant management of first trimester miscarriage. Hum Reprod. Feb 2004;19(2):266-71. [Medline].

  4. Callen PW. Ultrasound in Obstetrics and Gynecology. 4th ed. Philadelphia, Pa: WB Saunders; 2000.

  5. Cho FN, Chen SN, Tai MH, Yang TL. The quality and size of yolk sac in early pregnancy loss. Aust N Z J Obstet Gynaecol. Oct 2006;46(5):413-8. [Medline].

  6. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early pregnancy failure--current management concepts. Obstet Gynecol Surv. Feb 2001;56(2):105-13. [Medline].

  7. Demetroulis C, Saridogan E, Kunde D, Naftalin AA. A prospective randomized control trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod. Feb 2001;16(2):365-9. [Medline].

  8. Graziosi GC, Mol BW, Ankum WM, Bruinse HW. Management of early pregnancy loss. Int J Gynaecol Obstet. Sep 2004;86(3):337-46. [Medline].

  9. Hemminki E. Treatment of miscarriage: current practice and rationale. Obstet Gynecol. Feb 1998;91(2):247-53. [Medline].

  10. Hurd WW, Whitfield RR, Randolph JF, Kercher ML. Expectant management versus elective curettage for the treatment of spontaneous abortion. Fertil Steril. Oct 1997;68(4):601-6. [Medline].

  11. Lelaidier C, Baton-Saint-Mleux C, Fernandez H, et al. Mifepristone (RU 486) induces embryo expulsion in first trimester non-developing pregnancies: a prospective randomized trial. Hum Reprod. Mar 1993;8(3):492-5. [Medline].

  12. Luise C, Jermy K, May C, et al. Outcome of expectant management of spontaneous first trimester miscarriage: observational study. BMJ. Apr 13 2002;324(7342):873-5. [Medline].

  13. Morin L, Van den Hof MC. SOGC clinical practice guidelines. Ultrasound evaluation of first trimester pregnancy complications. Number 161, June 2005. Int J Gynaecol Obstet. Apr 2006;93(1):77-81. [Medline].

  14. [Best Evidence] Neilson JP, Hickey M, Vazquez J. Medical treatment for early fetal death (less than 24 weeks). Cochrane Database Syst Rev. Jul 19 2006;3:CD002253. [Medline].

  15. Ngoc NT, Blum J, Westheimer E, et al. Medical treatment of missed abortion using misoprostol. Int J Gynaecol Obstet. Nov 2004;87(2):138-42. [Medline].

  16. [Best Evidence] Petrou S, Trinder J, Brocklehurst P, Smith L. Economic evaluation of alternative management methods of first-trimester miscarriage based on results from the MIST trial. BJOG. Aug 2006;113(8):879-89. [Medline].

  17. Pridjian G, Moawad AH. Missed abortion: still appropriate terminology?. Am J Obstet Gynecol. Aug 1989;161(2):261-2. [Medline].

  18. [Best Evidence] Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ. May 27 2006;332(7552):1235-40. [Medline].

  19. [Best Evidence] Trinder J, Brocklehurst P, Porter R, Read M, Vyas S, Smith L. Management of miscarriage: expectant, medical, or surgical? Results of randomised controlled trial (miscarriage treatment (MIST) trial). BMJ. May 27 2006;332(7552):1235-40. [Medline].

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Further Reading

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Keywords

blighted ovum, anembryonic pregnancy, anembryonic gestation, pregnancy failure prior to 20 weeks gestation, spontaneous abortion, early pregnancy failure, fetal demise, mifepristone, Mifeprex, RU 486, RU-486, RU486, misoprostol, fetal chromosomal abnormalities, maternal disease, embryonic anomalies, placental abnormalities, uterine anomalies, ectopic pregnancy, intrauterine pregnancy

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Contributor Information and Disclosures

Author

James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of Medicine
James L Lindsey, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Society for Colposcopy and Cervical Pathology, and California Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Veronica R Rivera, MD, Staff Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Veronica R Rivera, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Suzanne R Trupin, MD, Clinical Professor of Obstetrics and Gynecology, University of Illinois College of Medicine-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center
Suzanne R Trupin, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard S Legro, MD, Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center
Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, and Society of Reproductive Surgeons
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

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